Kaiser Permanente Community Benefit Grants Program

EVENT/SPONSORSHIP/DONATION APPLICATION

San Mateo Area

KAISER PERMANENTE

NORTHERN CALIFORNIA REGION

SAN MATEO AREA

Helping Communities THRIVE

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Kaiser Permanente Community Benefit Grants Program

EVENT/SPONSORSHIP/DONATION APPLICATION

San Mateo Area

san mateo area community benefitevent/sponsorship application requirements

  • Requests for support for community activities (e.g. health fairs, dinners, health education forums, conferences/symposiums), volunteers, in-kind donations, may be submitted throughout the year.
  • All requests must be submitted in writing by using this 2014San Mateo Area Sponsorship Application at least one month prior to the event.

Your sponsorship request to the San Mateo Area Community Benefit must meet the following criteria:

  • Only nonprofit or public benefit organizations are eligible to receive funding. Unincorporated groups or agencies can make arrangements to utilize an eligible nonprofit organization as a fiscal agent.
  • Funds must be used to serve vulnerable populations in Kaiser Permanente’s San Mateo Area.
  • Your organization must address community needs in the areas of health and human services.
  • Funds must be spent by December 31, 2014.

Funding Limitations

Kaiser PermanenteSan Mateo Area Community Benefit will not consider funding requests from the following types of organizations or for the following activities/purposes:

  • Political campaigns*
  • Contributions to endowments or memorials
  • Emergency loans
  • Athletic programs
  • Field trips
  • Religious organizations (for religious purposes)**
  • Individuals and personal requests for scholarships, individual tuition, educational

purposes, conferences, etc.

  • Arts/recreation

*As a nonprofit organization, Kaiser Permanente is legally prohibited from funding political campaigns.

** Kaiser Permanente may fund faith organizations for programs that serve the greater community and are consistent with our community health priorities.

Kaiser Permanentecommunity benefit, san mateo area2014 event/sponsorship application

I. Contact Information

Date
Organization Name
Physical Street Address
City
State
Postal Code (9 digits) / -
Mailing Address / Same as physical address Other:
Phone
Fax
Website Address
Executive Director
Project Contact Person
Title
Project Contact Phone
Project Contact Email
For projects using a fiscal agent, complete the boxes below.
Fiscal Agent Organization Name
(if applicable)
Physical Street Address
City
State
Postal Code (9 digits) / -
Mailing Address / Same as physical address Other:
Phone
Fax
Website Address
Executive Director
Executive Director Phone
Executive Director Email

II.Organization Tax Information

Organization/Fiscal Agent Name (as reflected on IRS determination letter):
Organization Tax ID
Tax Status / / 501(c)(3) with 509(a) designation as a non-private foundation
/ School, local, state or federal government agency

III. Organization Information

Brief summary of organization’s history, mission, and goals
Description of current programs, activities, and accomplishments

IV. Event Information

Event title:
Location:
Event Date:
Amount requested:
Amount of tangible benefit (cost of meal or services provided), if applicable:
Total event budget:
Geographic area(s) to be served:
Community partners:
Kaiser Permanente groups/individuals involved:

V. Community Health Priority

Kaiser Permanente San Mateo Area priority addressed by this proposal:
Behavioral Health
Healthy Eating Active Living (HEAL)

VI. SPONSORSHIP Purpose

Description of event goals and objectives (include the # of clients impacted)

VII. Communications

Description of promotional activities, and a brief summary of how the outcomes of the event will be communicated and to whom

Attachments (All attachments must be included with application)

Request on letterhead from the requesting agency, signed by an authorized decision maker, stating the amount of funding requested

Copy of current IRS determination letter indicating tax-exempt status or an equivalent letter affirming public entity or school district tax-exempt status

List of current Board of Directors and their affiliations

List of other corporations, foundations, and other funding sources with amounts

For organizations using a Fiscal Agent(All attachments must be included with application)

Request on letterhead from the fiscal agent, signed by an authorized decision maker, stating the amount of funding requested

Copy of current IRS determination letter indicating tax-exempt status or an equivalent letter affirming public entity or school district tax-exempt status

List of current Board of Directors and their affiliations

Submission Instruction

Please submit completed application and attachments via email to:

* Supplemental materials such as photographs, videos, etc. may be submitted, but can not be returned.

Helping Communities THRIVE

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